Data Request Form

Great Plains Tribal Health Board (GPTCHB)
Great Plains Tribal Epidemiology Center (GPTEC)
Data Coordinating Center (DCC)

Step 1 of 10 - Terms and Conditions of Use

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Terms and Conditions of Use
***Please note that between Monday, December 23 and Monday, January 6, response to data requests will be delayed due to the holidays. We appreciate your patience during this time.
Any use of data provided by GPTCHB must be presented or published in a manner that protects individual identity. Every effort has been made to protect the identities of persons represented in the data provided to us. Data provided may only be used for the purposes for which it was requested.
In order for the GPTEC DCC to provide public health data to you, it is necessary that you agree to the following provisions:

I will not use - or permit others to use - the data in any way other than for statistical reporting and analysis. I must notify the GPTCHB if I discover that there has been any other use of the data.
I will not present or publish data in which an individual can be identified. I will not publish any information on an individual. In addition, I will avoid publication of statistics for very small groups.
I will not attempt either to link - or permit others to link - the data with individually identified records in another database.
If I inadvertently discover the identity of any individual, then (a) I will make no use of this knowledge, (b) I will notify the GPTCHB of the incident, and (c) I will inform no one else of the discovered identity.
I will cite the source of information in all publications. The appropriate citation is provided upon fulfillment of the data request.
I will not misrepresent myself, the organization with which I am affiliated, or how I intend to use the data.
Terms of use including the purpose, destruction, and publication of data will be agreed to before data are released.
Tribal Letters of Support and/or a Tribal Resolution may be required prior to the release of data.

Please select one:*
- Accept
- Decline

Contact Information:
Name:*
Phone:*
Email:*
Organization:*
Type of Organization:*
- Local Health
- State Health
- Tribal Health
- University
- News Media
- Other

Request Details:
How soon will you need the data?*
Date Format: MM slash DD slash YYYY
How will the data be used?*
Provide specific details on what data are needed.*

What time period would you like the data to include?*
- Most recent available
- Select custom dates (below)
How many years of data would you like?*
- One year
- Three years
- Five years
- Ten years
Would you like the data combined across the time period identified?*
- Yes
- No
Beginning Date:*
Date Format: MM slash DD slash YYYY
End Date:*
Date Format: MM slash DD slash YYYY
Would you like the data combined across the time period identified?*
- Yes
- No

What ages would you like the data to include?*
- All ages combined
- Individual years of age
- Custom age groups
Please specify age range(s) or ages desired.*
Would you like the data combined across the ages or range(s) identified?*
- Yes
- No
Please specify custom age group(s) desired.*
Would you like the data combined across the age group(s) identified?*
- Yes
- No

Which sex categories are requested?*

Which categories of race are requested?*
- All races (combined)
- All races (not combined)
- Select race(s) of interest
*
- American Indian/Alaska Native
- African American
- White
- Asian
- Native Hawaiian/Pacific Islander
Would you like the data combined across the race categories selected?*
- Yes
- No
Do you want to be able to identify persons of Hispanic or Latino origin?*
- Yes
- No

What is the geographic coverage of the data?*
*
- I understand that GPTEC will require permission from Tribal Health Directors/Administrators to share tribal-specific data.
For which tribes are data being requested?*
- All Great Plains Area Tribes
- Cheyenne River Sioux Tribe
- Crow Creek Sioux Tribe
- Flandreau Santee Sioux Tribe
- Lower Brule Sioux Tribe
- Mandan, Hidatsa, Arikara Nation
- Oglala Sioux Tribe
- Omaha Tribe of Nebraska
- Ponca Tribe of Nebraska
- Rosebud Sioux Tribe
- Sac and Fox Tribe of the Mississippi
- Santee Sioux Nation
- Sisseton-Wahpeton-Oyate
- Spirit Lake Dakota Nation
- Standing Rock Sioux Tribe
- Trenton Indian Service Area
- Turtle Mountain Band of Chippewa
- Winnebago Tribe of Nebraska
- Yankton Sioux Tribe
Provide details of the geographic area (i.e. list state(s), county(ies)):*
Would you like the data combined across the (tribes, counties, states) selected?*
- Yes
- No

Please tell us about your experience:
How did you hear about the GPTEC Data Request Portal?*
How would you describe the usability of the online data request form?*
What suggestions do you have for improving the online data request form or the data request process?*

Policy Summary:
All data requests are subject to availability. The DCC will make every effort to fulfill requests in a timely manner. Data requests can take two weeks or longer to complete. The DCC retains the right to deny requests for any reason.
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